CurrentUnitedHealthcarePolicy CS364KS.02

Minimally Invasive Spine Surgery Procedures (for Kansas Only)

UnitedHealthcare policy (Kansas only) describing medical necessity, investigational/unproven determinations, definitions, evidence review, and applicable procedure codes for minimally invasive spine surgery procedures including AxiaLIF, PILD/MILD, sacroplasty, LALIF, endoscopic discectomy, PLDD, and related techniques. This is Part 1 of 2 and contains coverage rationale, definitions, evidence summaries, and an applicable codes list.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Spine Surgery Procedures (for Kansas Only)

Policy CodePolicy CS364KS.02

Change TypeDefinitions and CPT annual edits (03/01/2026)

Effective DateMarch 1, 2026

Next Review Date

Key ActionProviders must refer to InterQual CP criteria (Decompression +/- Fusion, Lumbar; Fusion, Lumbar Spine) for clinical medical necessity determinations for minimally invasive spine surgeries.

SourceLink

POLICY UPDATE CHANGES

Added CPT codes 62330 and 62331 to applicable codes list.

Removed CPT code 0275T from applicable codes list.

Revised description for CPT 62287.

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

Added definition of 'Transforaminal Lumbar Interbody Fusion'.

Removed definitions of Interlaminar Lumbar Instrumented Fusion (ILIF); Nucleoplasty; Percutaneous or Endoscopic Lumbar Fusion; Transforaminal (TESSYS®) and Interlaminar Endoscopic Surgical Systems; Tubular Retractor.

Updated definitions for multiple items including APLD, AxiaLIF, Endoscope, Endoscopic Discectomy, Fluoroscopy, MILD®, Interbody Fusion, LALIF, Open Spine Surgery, PELD, PILD, Posterior Lumbar Spine Surgery, Sacroplasty.

5Procedures listed as unproven/not medically necessary in Part 1

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Coverage Summary

Scope summary: UnitedHealthcare (Kansas-only) policy CS364KS.02 addresses medical necessity, investigational/unproven determinations, definitions, evidence summaries, and applicable procedure codes for minimally invasive spine surgery procedures including Axial Lumbar Interbody Fusion (AxiaLIF), Percutaneous Image-Guided Lumbar Decompression (PILD) / MILD®, percutaneous sacral augmentation (sacroplasty), Laparoscopic Anterior Lumbar Interbody Fusion (LALIF), endoscopic discectomy, and percutaneous laser/needle-based decompression (PLDD). (Part 1 of 2.)

Coverage stance: Mixed — several listed procedures (AxiaLIF, PILD, sacroplasty, MILD®, LALIF) are designated in this policy as unproven and not medically necessary due to insufficient evidence, while InterQual CP criteria are to be used for definitive medical necessity determinations for decompression and fusion procedures.

Effective date: March 1, 2026 (policy effective date).

Part designation: Part 1 of 2 — contains coverage rationale, definitions, evidence summaries, and applicable codes.

High-level procedures addressed: AxiaLIF; PILD / MILD®; sacroplasty; LALIF; endoscopic discectomy; PLDD. InterQual clinical practice (Decompression +/- Fusion, Lumbar; Fusion, Lumbar Spine) is referenced and used by UnitedHealthcare for definitive medical necessity determinations.

Selected numeric highlights

Studies in Chandra et al.19 studies (n=861)

Technical success rate98.9% (Chandra et al.)

Clinical success rate95.7% (Chandra et al.)

Cement leakage complication rate0.3% (Chandra et al.)

Hayes evolving Evidence Report date2023 (updated Nov 2024)

Medical-Necessity Criteria

Reference to InterQual criteria for medical necessity

For medical necessity clinical coverage criteria for minimally invasive spine surgeries, refer to the InterQual CP:

InterQual reference: Decompression +/- Fusion, Lumbar — use InterQual CP criteria (linked resource)

InterQual reference: Fusion, Lumbar Spine — use InterQual CP criteria (linked resource)

Coverage Rationale / Unproven and Not Medically Necessary

The following spinal procedures are designated unproven and not medically necessary due to insufficient evidence of efficacy:

Unproven/not medically necessary list: Axial Lumbar Interbody Fusion (AxiaLIF), a percutaneous Presacral access route to the L5 to S1 vertebral bodies

Clinical Evidence and Limitations

Clinical evidence summary for percutaneous sacroplasty

Evidence-based conclusions and limitations summarized from systematic reviews, retrospective studies, and evolving evidence reports:

Hayes evolving report: Hayes evolving Evidence Report (2023, updated Nov 2024) concluded minimal support for percutaneous sacroplasty for SIFs due to causes other than malignancy; overall body of evidence is poor and additional research is needed.

Guideline/position statements confer no/unclear support.

Chandra et al. 2019 meta-analysis: Chandra et al. (2019) systematic review/meta-analysis (19 studies, n=861) reported high technical success (98.9%), clinical success (95.7%), and low complication rate (cement leakage 0.3%); significant VAS pain score improvements up to 12 months but limitations include heterogeneity, mostly retrospective case series, and no RCTs.

Pain VAS scores: pre 8.32; 24-48h 3.55; 6mo 1.48; 12mo 0.923 (±0.01)

Andresen et al. 2022: Andresen et al. (2022) retrospective study (292 patients) found sacroplasty associated with faster pain reduction, improved mobility, greater independence over 2 years and lower 12-month mortality compared with conservative treatment in select patients; limitations include retrospective design and treatment selection bias.

Definitions

Axial Lumbar Interbody Fusion (AxiaLIF): Minimally invasive presacral/trans-sacral/transaxial/paracoccygeal technique to access L5–S1 for interbody fusion.

Endoscope: A diagnostic instrument equipped with illumination designed for direct visualization of internal anatomical structures.

Endoscopic Discectomy: Minimally invasive removal of herniated disc material from the spine using an endoscope.

Fluoroscopy: Radiological imaging used to position instruments during diagnostic and surgical procedures.

Image-Guided Minimally Invasive Lumbar Decompression (MILD®): An image-guided, minimally invasive procedure used to decompress the lumbar spine when central canal stenosis is caused by a thickened ligamentum flavum.

Laparoscopic Anterior Lumbar Interbody Fusion (LALIF): A minimally invasive endoscopic anterior approach via small abdominal incisions to fuse lumbar vertebrae.

Percutaneous Image-Guided Lumbar Decompression (PILD): Percutaneous image-guided removal of thickened tissue to enlarge the spinal canal in posterior lumbar spinal stenosis.

Open Spine Surgery: Surgery involving a long incision to expose the surgical area for direct visualization and access.

Presacral: Anatomical region anterior to the sacrum.

Sacroplasty: Percutaneous placement of polymethyl methacrylate cement into the site of a sacral insufficiency fracture to provide mechanical stabilization and pain relief.

Coding

Procedure codes referenced (for reference only)CPT

0200T	Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed.
0201T	Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed.
22586	Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace.
22630	Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar.
22899	Unlisted procedure, spine.
62287	Decompression, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle-based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar.
62330	Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (i.e., CT or fluoroscopy), bilateral; one interspace, lumbar.
62331	Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (i.e., CT or fluoroscopy), bilateral; additional interspace(s), lumbar (List separately in addition to code for primary procedure).
62380	Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar.
G0276	Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (PILD) or placebo-control, performed in an approved coverage with evidence development (CED) clinical trial.

Applicable CPT codes - annual edits noted in policy historyCPT

62330	Added to list of applicable CPT codes (per Policy History 03/01/2026)
62331	Added to list of applicable CPT codes (per Policy History 03/01/2026)
0275T	Removed from list of applicable CPT codes (per Policy History 03/01/2026)
62287	Description revised (per Policy History 03/01/2026)

Provider Actions

Prior Authorization

Prior authorization and medical necessity

Prior authorization is required and UnitedHealthcare will evaluate requests for medical necessity. Document the following elements in the prior authorization record: • Indication for the procedure (specific diagnosis and anatomic site). • Fracture etiology (e.g., osteoporotic insufficiency fracture, traumatic fracture, metastatic disease). • Pain severity and functional impact (duration, severity, and effect on activities of daily living). • Prior conservative treatment and response (e.g., analgesics, activity modification, physical therapy, bracing, osteoporotic medical therapy) including dates and duration. Failure to provide complete documentation may result in delayed review or denial.

Indication (diagnosis and site)
Fracture etiology (osteoporotic, traumatic, metastatic, other)
Pain severity and functional impact (duration, effect on ADLs)
Prior conservative treatments and responses (with dates and duration)

Denial Risk

Procedures considered unproven — potential denial

FDA Information

FDA information (informational only): A variety of endoscopes and associated surgical instruments and devices used in minimally invasive spine procedures have received FDA 510(k) marketing clearance. UnitedHealthcare provides the FDA device search link for reference. FDA clearance or approval alone is explicitly not a basis for coverage.

Evidence References

Source	Summary
ECRI report (AxiaLIF)
Evidence from case series at high risk of bias; insufficient to support safety and effectiveness of AxiaLIF (ECRI, 2020).
Hayes assessment (sacroplasty)
Hayes evolving Evidence Report (2023, updated Nov 2024) concluded minimal support for percutaneous sacroplasty for sacral insufficiency fractures due to causes other than malignancy; overall body of evidence is poor and additional research needed.
RCTs for MILD/PILD
Multiple RCTs and systematic reviews (e.g., Staats et al. 2018, Brown 2012, Zhang et al. 2025) show symptomatic improvement up to 1–2 years but limitations and uncertainty about long-term durability.
Hayes evolving conclusion (duplicate entry)
Hayes report reiterated minimal support and poor overall evidence for sacroplasty; further RCTs recommended (Hayes, 2023; updated Nov 2024).
Chandra et al.
Systematic review/meta-analysis (19 studies, n=861) reported high technical success (98.9%), clinical success (95.7%), low complication rate (cement leakage 0.3%), and significant VAS pain improvements up to 12 months; limitations include heterogeneity and lack of RCTs.
Andresen et al.
Retrospective study (n=292) found sacroplasty associated with faster pain reduction, improved mobility, greater independence over 2 years and lower 12-month mortality vs conservative treatment in select patients; limited by retrospective design and selection bias.

Revision History

03/01/2026definitions_addedLatest

Added definition of 'Transforaminal Lumbar Interbody Fusion' (Policy History 03/01/2026).

03/01/2026definitions_removedLatest

Removed definitions: Interlaminar Lumbar Instrumented Fusion (ILIF); Nucleoplasty; Percutaneous or Endoscopic Lumbar Fusion; Transforaminal (TESSYS®) and Interlaminar Endoscopic Surgical Systems; Tubular Retractor (Policy History 03/01/2026).

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Spine Surgery Procedures (for Kansas Only)

Policy CodePolicy CS364KS.02

Change TypeDefinitions and CPT annual edits (03/01/2026)

Effective DateMarch 1, 2026

Next Review Date

Key ActionProviders must refer to InterQual CP criteria (Decompression +/- Fusion, Lumbar; Fusion, Lumbar Spine) for clinical medical necessity determinations for minimally invasive spine surgeries.

SourceLink

On This Page

Overall evidence quality: The policy summarizes that the body of evidence for many minimally invasive spine procedures is limited and of low quality — consisting largely of case series, retrospective studies, and small or heterogeneous trials — and that additional high-quality randomized controlled trials are needed to establish safety, comparative effectiveness, and long-term durability.

Guideline and society positions: Systematic reviews and guideline/position statements provide mixed or limited support. Examples cited include AANS/CNS guidance on fusion indications, NASS guidance noting insufficient evidence for some minimal-access treatments, and ISASS recommendations addressing interlaminar stabilization; overall, guideline statements often confer no or unclear support for many emerging minimally invasive techniques.

Technology assessments: Independent assessments and technology reviews (ECRI, Hayes) have concluded that evidence is insufficient for certain procedures. ECRI found the AxiaLIF evidence at high risk of bias and inadequate to support safety and effectiveness. Hayes evolving and HTA reports (sacroplasty, PILD/MILD, endoscopic discectomy/PLDD) concluded minimal or low-quality support for some indications, observed short-term symptom improvement in select studies, but emphasized uncertainty about long-term outcomes and the need for larger RCTs.

Specific syntheses and limitations: Meta-analyses and systematic reviews (e.g., Chandra et al. for sacroplasty; Zhang et al. and Merkow et al. for MILD®) report high technical/clinical success rates or short-term symptom improvements in some series and RCTs, but heterogeneity, selection bias, lack of randomized sham- or open-surgery comparisons, and limited long-term data restrict definitive conclusions about net health benefit.

Regulatory note: FDA 510(k) clearances exist for various endoscopes and related instruments, but FDA marketing clearance is explicitly noted as informational only and is not a basis for coverage.

Documentation Required

Verify federal, state, or contractual benefit plan requirements

Verify federal, state, or contractual benefit plan requirements prior to authorization or claim submission. These requirements and applicable laws may govern coverage determinations and can supersede standard policy language; coordination with the member’s specific benefit plan is required.

Confirm federal/state mandates and waivers that apply to the member
Review the member’s contract/benefit plan for any differing coverage terms or benefit limits
When state or contractual terms differ from policy, the federal/state/contractual terms govern

Denial Risk

Denial risk for non-supported indications

There is a denial risk when sacroplasty or other minimally invasive sacral augmentation procedures are performed for indications not supported by evidence (for example, routine osteoporotic sacral pain without imaging-confirmed insufficiency fracture, or metastatic disease without clear palliative indication). Prior authorization with supporting documentation is advised to reduce the risk of denial.

Denial risk when sacroplasty performed for non–evidence-supported indications (e.g., nonspecific sacral pain without confirmed fracture)
Provide imaging and clinical correlation to support the indication for sacroplasty
Procedures listed as unproven in policy are subject to denial if documentation does not justify medical necessity